| Organization Name: | PINE RIDGE EXTENDED CARE CENTER, LLC |
| NPI Number: | 1336206010 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MARY BROOKS (ADMINISTRATOR) |
| Mailing Address: | 119 Bastille Dr Pagosa Springs |
| State: | CO US |
| Postal Code: | 811479388 |
| Phone Number: | 9707314330 |
| Fax Number: | 9707314046 |
| NPI Enumeration Date: | 01/02/2007 |
| NPI Last Update Date: | 07/09/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 385H00000X |
| License Number: | 0105 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CO |
| Taxonomy Type: | Respite Care Facility |
| Taxonomy Classification: | Respite Care |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |